Provider Demographics
NPI:1881364941
Name:PRIME PEDIATRICS LLP
Entity type:Organization
Organization Name:PRIME PEDIATRICS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:615-476-7812
Mailing Address - Street 1:765 NANCY SHAWL RD
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-5010
Mailing Address - Country:US
Mailing Address - Phone:615-476-7812
Mailing Address - Fax:
Practice Address - Street 1:300 S CLYDETON RD
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-2140
Practice Address - Country:US
Practice Address - Phone:615-476-7812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care